Haemorrhoids

Hemorrhoids (commonly known as piles) can produce symptoms of itching, burning, pain, swelling and discomfort in the perianal area and anal canal and rectal bleeding. Haemorrhoids are swollen veins, rather like varicose veins, which protrude into the anal canal (internal piles). They may swell so much that they hang down outside the anus (external piles). Hemorrhoids are often caused or exacerbated by inadequate dietary fibre or fluid intake. The pharmacist must, by careful questioning, differentiate between this minor condition and others that may be potentially more serious.

What you need to know

Duration and previous history, Symptoms, Itching, burning, Soreness, Swelling, Pain, Blood in stools, Constipation, Bowel habit, Pregnancy, Other symptoms, Abdominal pain/vomiting, Weight loss, Medication, Significance of questions and answers

Duration and previous history

As an arbitrary guide, the pharmacist might consider treating hemorrhoids of up to 3 weeks’ duration. It would be useful to establish whether the patient has a previous history of haemorrhoids and if the doctor has been seen about the problem. A recent examination by the doctor that has excluded serious symptoms would indicate that treatment of symptoms by the pharmacist would be appropriate.

Symptoms

The term haemorrhoids includes internal and external piles, which can be further classified as (1) those which are confined to the anal canal and cannot be seen; (2) those which prolapse through the anal sphincter on defaecation and then reduce by themselves or are pushed back through the sphincter after defaecation by the patient; (3) those which remain persistently prolapsed and outside the anal canal. These three types are sometimes referred to as first, second and third degree, respectively. Predisposing factors for haemorrhoids include diet, sedentary occupation and pregnancy and there is thought to be a genetic element.

Pain

Pain is not always present; if it is, it may take the form of a dull ache and may be worse when the patient is having a bowel movement. A severe, sharp pain on defaecation may indicate the presence of an anal fissure, which can have an associated sentinel pile (a small skin tag at the posterior margin of the anus) and requires referral. A fissure is a minute tear in the skin of the anal canal. It is usually caused by constipation and can often be managed conservatively by correcting this and using a local anaesthetic-containing cream or gel. In severe cases a minor operation is sometimes necessary.

Irritation

The most troublesome symptom for many patients is itching and irritation of the perianal area rather than pain. Persistent or recurrent irritation, which does not improve, is sometimes associated with rectal cancer and should be referred.

Bleeding

Blood may be deposited onto the stool from internal haemorrhoids as the stool passes through the anal canal. This fresh blood will appear bright red. It is typically described as being splashed around the toilet pan and may be seen on the surface of the stool or on the toilet paper. If blood is mixed with the stool, it must have come from higher up the Gastrointestinal tract and will be dark in colour (altered blood).

If rectal bleeding is present, the pharmacist would be well advised to suggest that the patient see the doctor so that an examination can be performed to exclude more serious pathology such as tumour or polyps. Colorectal cancer can cause rectal bleeding. The disease is unusual in patients under 50 and the pharmacist should be alert for the middle-aged patient with rectal bleeding. This is particularly so if there has been a significant and sustained alteration in bowel habit.

Constipation

Constipation is a common causatory or exacerbatory factor in hemorrhoids. Insufficient dietary fibre and inadequate fluid intake may be involved, and the pharmacist should also consider the possibility of drug-induced constipation.

Straining at stool will occur if the patient is constipated; this increases the pressure in the haemorrhoidal blood vessels in the anal canal and hemorrhoids may result. If piles are painful, the patient may try to avoid defaecation and ignoring the call to open the bowels will make the constipation worse.

Bowel habit

A persisting change in bowel habit is an indication for referral, as it may be caused by a bowel cancer. Seepage of fecal material through the anal sphincter (one form of faecal incontinence) can produce irritation and itching of the perianal area and may be caused by the presence of a tumour.

Pregnancy

Pregnant women have a higher incidence of haemorrhoids than non-pregnant women. This is thought to be due to pressure on the hemorrhoidal vessels due to the gravid uterus. Constipation in pregnancy is also a common problem because raised progesterone levels mean that the gut muscles tend to be more relaxed. Such constipation can exacerbate symptoms of hemorrhoids. Appropriate dietary advice can be offered by the pharmacist (see the chapter on ‘Women’s health’).

Other symptoms

Symptoms of hemorrhoids remain local to the anus. They do not cause abdominal pain, distension or vomiting. Any of these more widespread symptoms suggest other problems and require referral.

Tenesmus (the desire to defecate when there is no stool present in the rectum) sometimes occurs when there is a tumour in the rectum. The patient may describe a feeling of often wanting to pass a motion but no faeces being present. This symptom requires urgent referral.

Medication

Patients may already have tried one or more proprietary preparations to treat their symptoms. Some of these products are advertised widely, since the problem of haemorrhoids is perceived as potentially embarrassing and such advertisements may sometimes discourage patients from describing their symptoms. It is therefore important for the pharmacist to identify the exact nature of the symptoms being experienced and details of any products used already. If the patient is constipated, the use of any laxatives should be established.

Present medication

Haemorrhoids may be exacerbated by drug-induced constipation and the patient should be carefully questioned about current medication, including prescription and over the counter medicines. Rectal bleeding in a patient taking warfarin or another anticoagulant is an indication for referral.

When to refer

Duration of longer than 3 weeks

Presence of blood in the stools

Change in bowel habit (persisting alteration from normal bowel habit)

Suspected drug-induced constipation

Associated abdominal pain/vomiting

Treatment timescale

If symptoms have not improved after 1 week, patients should see their doctor.

Management

Symptomatic treatment of haemorrhoids can provide relief from discomfort but, if present, the underlying cause of constipation must also be addressed. The pharmacist is in a good position to offer dietary advice, in addition to treatment, to prevent the recurrence of symptoms in the future.

Local anaesthetics (e.g. benzocaine and lidocaine (lignocaine))

Local anesthetics can help to reduce the pain and itching associated with hemorrhoids. There is a possibility that local anaesthetics may cause sensitisation and their use is best limited to a maximum of 2 weeks.

Skin protectors

Many antihaemorrhoidal products are bland, soothing preparations containing skin protectors (e.g. zinc oxide and kaolin). These products have emollient and protective properties. Protection of the perianal skin is important, because the presence of fecal matter can cause symptoms such as irritation and itching. Protecting agents form a barrier on the skin surface, helping to prevent irritation and loss of moisture from the skin.

Topical steroids

Ointment and suppositories containing hydro cortisone with skin protectors are available. The steroid reduces inflammation and swelling to give relief from itching and pain. The treatment should be used each morning and at night and after a bowel movement. The use of such products is restricted to those over 18. Treatment should not be used continuously for longer than 7 days.

Astringents

Astringents such as zinc oxide, hamamelis (witch hazel) and bismuth salts are included in products on the theoretical basis that they will cause precipitation of proteins when applied to mucous membranes or skin which is broken or damaged. A protective layer is then thought to be formed, helping to relieve irritation and inflammation. Some astringents also have a protective and mild antiseptic action (e.g. bismuth).

Antiseptics

These are among the ingredients of many antihaemorrhoidal products, including the medicated toilet tissues. They do not have a specific action in the treatment of hemorrhoids. Resorcinol has antiseptic, antipruritic and exfoliative properties. The exfoliative action is thought to be useful by removing the top layer of skin cells and aiding penetration of medicaments into the skin. Resorcinol can be absorbed systemically via broken skin if there is prolonged use and its antithyroid action can lead to the development of myxoedema (hypothyroidism).

Counterirritants

Counterirritants such as menthol are sometimes included in antihemorrhoidal products on the basis that their stimulation of nerve endings gives a sensation of cooling and tingling, which distracts from the sensation of pain. Menthol and phenol also have antipruritic actions.

Shark liver oil/live yeast

These agents are said to promote healing and tissue repair, but there is no scientific evidence to support such claims.

Laxatives

The short-term use of a laxative to relieve constipation might be considered. A stimulant laxative (e.g. senna) could be supplied for 1 or 2 days to help deal with the immediate problem while dietary fibre and fluids are being increased. For patients who cannot or choose not to adapt their diet, bulk laxatives may be used long term.

Practical points

Self-diagnosis

Patients may say that they have piles, or think they have piles, but careful questioning by the pharmacist is needed to check whether this self-diagnosis is correct. If there is any doubt, referral is the best course of action.

Hygiene

The itching of hemorrhoids can often be improved by good anal hygiene, since the presence of small amounts of fecal matter can cause itching. The perianal area should be washed with warm water as frequently as is practicable, ideally after each bowel movement. Soap will tend to dry the skin and could make itching worse, but a mild soap could be tried if the patient wishes to do so. Moist toilet tissues are available and these can be very useful where washing is not practical, e.g. at work during the daytime, and some patients prefer them. These tissues are better used with a patting rather than a rubbing motion, which might aggravate symptoms. Many people with haemorrhoids find that a warm bath soothes their discomfort.

An increased intake of dietary fibre will increase bowel output, so patients should be advised to take care in wiping the perianal area and to use soft toilet paper to avoid soreness after wiping.

How to use over the counter products

Ointments and creams can be used for internal and external hemorrhoids and should be applied in the morning, at night and after each bowel movement. An applicator is included in packs of ointments and creams and patients should be advised to take care in its use, to avoid any further damage to the perianal skin.

Suppositories can be recommended for internal haemorrhoids. After removing the foil or plastic packaging (patients have been known to try and insert them with the packaging left on), a suppository should be inserted in the morning, at night and after bowel movements. Insertion is easier if the patient is crouching or lying down.

Haemorrhoids in practice

Case 1

Tom Harris, a customer whom you know quite well, asks if you can recommend something for his usual problem. You ask him to tell you more about it: Mr Harris suffers from piles occasionally; you have dispensed prescriptions for Anusol HC and similar products in the past and have previously advised him about dietary fibre and fluid intake. He has been away on holiday for 2 weeks and says he hasn’t been eating the same foods he does when at home. His symptoms are itching and irritation of the perianal area but no pain and he has a small swelling, which hangs down from the anus after he has passed a motion, but which he is able to push back again. He is a little constipated, but he is not taking any medicines.

The pharmacist’s view

Mr Harris has a previous history of hemorrhoids, which have been diagnosed and treated by his doctor. It is likely that his holiday and temporary change in diet have caused a recurrence of the problem, so he now has a second-degree pile, and it would be reasonable to suggest symptomatic treatment for a few days. You could recommend the use of an ointment preparation containing hydro cortisone and skin protectors for up to 1 week and remind Mr Harris that the area should be kept clean and dry.

You might consider recommending a laxative to ease the constipation until Mr Harris’s diet gets back to normal (you advise that he returns to his usual high-fibre diet) and makes sure his daily fluid intake is sufficient; a small supply of a stimulant laxative (perhaps a stimulant/stool softener such as docusate sodium) would be reasonable. He should see his doctor after 1 week if the problem has not cleared up.

The doctor’s view

The treatment suggested by the pharmacist should settle Mr Harris’s symptoms within 1 week. The treatment is, of course, symptomatic and not curative. If he continues to suffer from frequent relapse, referral should be considered. His doctor could advise whether or not to refer him for injection or removal of the piles.

Case 2

Mr Briggs is a local shopkeeper in his late fifties who wants you to recommend something for his piles. He tells you that he has had them for quite a while – a couple of months. He has tried several different ointments and suppositories, all to no avail. The main problem now is bleeding, which has become worse. In fact he tells you, somewhat embarrassed, that he has been buying sanitary towels because this is the only way he can prevent his clothes from becoming stained. He is not constipated and has no pain.

The pharmacist’s view

Mr Briggs should be referred to his doctor at once. His symptoms have a history of 2 months and there must be quite profuse rectal bleeding, which may well be due to a more serious disease. He has already tried some over the counter treatments, with no success. His age and the description of his symptoms mean that further investigation is needed.

The doctor’s view

Mr Briggs should be advised to see his doctor. This is not a typical presentation of piles. He will need a more detailed assessment by his doctor who will need to look for a cancer of the colon or rectum. Piles can bleed at times other than when defecating, but this is uncommon. The doctor would gather more information by questioning and from an examination. The examination would usually include a digital rectal assessment to determine whether or not a rectal tumour is present. It is quite likely that this man would require outpatient hospital referral for further investigations, which would involve sigmoidoscopy and barium enema.

Case 3

Caroline Andrews is a young woman in her mid-twenties, who works as a graphic designer in a local art studio. She asks your advice about an embarrassing problem: she is finding it very painful to pass motions. On questioning, she tells you that she has had the problem for a few days and has been constipated for about 2 weeks. She eats a diet that sounds relatively low in fibre and has been eating less than usual because she has been very busy at work. Caroline says she seldom takes any exercise. She takes the contraceptive pill but is not taking any medicines and has no other symptoms such as rectal bleeding.

The pharmacist’s view

Caroline would probably be best advised to see her doctor, since the symptoms and pain which she has described might be due to an anal fissure, though they may be caused by a hemorrhoid.

The doctor’s view

An anal fissure would be the most likely cause of Caroline’s problem. An examination by her doctor should quickly confirm this. Correction of the constipation and future preventative dietary advice could well solve the problem. The discomfort could be helped by a local anaesthetic-containing cream or gel. If this is applied prior to a bowel action, the discomfort would be less. In severe cases that are not settling, referral to a specialist surgeon is necessary in order to release one of the muscles in spasm for rapid relief of pain. Topical nitrate (e.g. GTN 0.2-0.3% ointment) is now also used by hospital specialists to treat anal fissure (unlicensed indication).